Gabriel Ray L.

Luzano 2010-58585

Philo 174 October 12, 2012

Should Doctors Still Follow the Custom of Giving Free Medical Service to Fellow Doctors According to the Hippocratic Oath? Growing up in the province, I have been told again and again by the old people the phrase doctors dont get sick which is, of course not true. But given the fact that I was little and didnt know otherwise I believed this. Being the son of two doctors, Ive personally observed that they never got sick which further made me believe the statement. But now I know that they just seem to not get sick and when they do, they can usually take care of themselves. When doctors cannot handle their illness, thats when it gets interesting. They go to their colleagues and they get their help. But I noticed that when other doctors visit my parents for check-ups and prescriptions they left smiling and my mom or dad would be doing an obviously fake smile behind their backs. I asked them about this and they told me that they didnt like providing services for other medical practitioners because they are not required to pay and when I asked them why they only said that it is a custom in the medical field because of the Hippocratic Oath. Fast forward twelve years into the future. One of the pertinent topics of bioethics is the patient-physician relationship. Randall and Downie explored this topic in chapter two of their book Palliative Care Ethics: A Good Companion. They explain the many aspects about the patient-physician relationship such as the patients aims in the relationship and the physicians aims in the relationship and even the inequalities between physicians and their patients.1 However the situation that I am particularly interested in is when the patient is also a physician. If the patient is also a physician many of the inequalities that Randall and Downie mentioned can be removed. For example, a physician would better understand what his colleague would be talking about; he would not be as intimidated by the expert in front of him as a normal patient would; etc. But alas, Randall and Downie, as well as many bioethics books do not delve into this topic. So I ask the question in the context of this day and age and in the Philippine context:

Fiona Randall and R.S. Downie, The Patient-Carer Relationship, Palliative Care Ethics: A Good Companion, (Oxford Medical Publications: Oxford University Press, 1996).

Should doctors still follow the custom of giving free medical service to fellow doctors according to the Hippocratic Oath? The Hippocratic Oath is perhaps one of the oldest binding documents in history and has been used in varying versions by physicians and other health practitioners for about 2000 years as some form of rite of passage after finishing their medical education or upon graduation and marking their entrance to the professional practice of medicine. The oath contains the various virtues, ethical conducts, and principles that all medical practitioners share and must uphold at all times. It has been widely believed that the proponent of the oath is Hippocrates, hence the name Hippocratic Oath but according to recent studies it most probably originated from a Pythagorean sect of the 4th century B.C.[2][3] The Hippocratic Oath states: I swear by Apollo the Healer, by Aesculapius, by Health and all the powers of healing and to call witness all the Gods and Goddesses that I may keep this oath and promise to the best of my ability and judgment. I will pay the same respect to my master in the science as to my parents and share my life with him and pay all my debts to him. I will regard his sons as my brothers and teach them the science, if they desire to learn it, without fee or contract. I will hand on precepts, lectures and all other learning to my sons, to those of my master and to those pupils duly appointed and sworn and to none other. I will use my power to help the sick to the best of my ability and judgment. I will abstain from harming or wrong doing any man by it. I will not give a fatal draught to anyone if I am asked, nor will I suggest any such thing. Neither will I give a woman means to procure an abortion. I will be chaste and religious in my life and in my practice. I will not cut, even for the stone, but I will leave such procedures to the practitioners of that craft. Whenever I go into a house I will go to help the sick and never with the intention of doing harm or injury. I will not abuse my position to indulge in sexual contacts with the bodies of women or of men whether they be freemen or slaves. Whatever I see or hear, whether professionally or privately which ought

The Oath: Meaningless Relic or Invaluable Moral Guide. The Hippocratic Oath Today (http://www.pbs.org/wgbh/nova/body/hippocratic-oath-today.html). 3 Hippocratic Oath. Microsoft Student 2009 [DVD]. Redmond WA: Microsoft Corporation, 2008.

not to be divulged I will keep secret and tell no one. If therefore, I observe this oath and do not violate it, may I prosper both in my life and in my profession, earning good repute among all men for all time. If I transgress and foreswear this oath, may my lot be otherwise.4 But a more modern version of the oath states that: I swear to fulfill, to the best of my ability and judgment, this covenant: I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow. I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism. I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug. I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery. I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God. I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick. I will prevent disease whenever I can, for prevention is preferable to cure. I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.
4

Peter Horn, Clinical Ethics Casebook (Wadsworth Publishing Company, 1999), pp. 176-177.

If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.5 And another modern version goes like this: You do solemnly swear, each by whatever he or she holds most sacred That you will be loyal to the Profession of Medicine and just and generous to its members That you will lead your lives and practice your art in uprightness and honor That into whatsoever house you shall enter, it shall be for the good of the sick to the utmost of your power, your holding yourselves far aloof from wrong, from corruption, from the tempting of others to vice That you will exercise your art solely for the cure of your patients, and will give no drug, perform no operation, for a criminal purpose, even if solicited, far less suggest it That whatsoever you shall see or hear of the lives of men or women which is not fitting to be spoken, you will keep inviolably secret These things do you swear. Let each bow the head in sign of acquiescence And now, if you will be true to this, your oath, may prosperity and good repute be ever yours; the opposite, if you shall prove yourselves forsworn.6 It is quite obvious that the Hippocratic Oath has undergone many revisions over time. But perhaps the most drastic of all would be the new oath that medical practitioners take, Declaration of Geneva, which completely changes the name and many other things: I SOLEMNLY PLEDGE myself to consecrate my life to the service of humanity; I WILL GIVE to my teachers the respect and gratitude which is their due;
5

Hippocratic Oath: Modern Version. The Hippocratic Oath Today (http://www.pbs.org/wgbh/nova/body/hippocratic-oath-today.html). 6 Microsoft Student 2009 [DVD], loc. cit.

I WILL PRACTICE my profession with conscience and dignity; THE HEALTH OF MY PATIENT will be my first consideration; I WILL RESPECT the secrets which are confided in me, even after the patient has died; I WILL MAINTAIN by all the means in my power, the honor and the noble traditions of the medical profession; MY COLLEAGUES will be my sisters and brothers; I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, or social standing to intervene between my duty and my patient; I WILL MAINTAIN the utmost respect for human life from its beginning even under threat and I will not use my medical knowledge contrary to the laws of humanity; I MAKE THESE PROMISES solemnly, freely and upon my honor.7 In the classical version of the oath, the custom of giving free medical service comes from the passage . I will pay the same respect to my master in the science as to my parents and share my life with him and pay all my debts to him. I will regard his sons as my brothers and teach them the science, if they desire to learn it, without fee or contract. It is stated here that anyone who takes this oath must treat his teacher and his teachers sons in the same way as he will treat his own and for free, of course. But in the first modern version of the oath that I have stated above, this entire passage of giving for free has been completely removed. In the second modern version also stated above there is the passage That you will be loyal to the Profession of Medicine and just and generous to its members. And in the Declaration of Geneva version it is stated, although very vaguely, that MY COLLEAGUES will be my sisters and brothers.

Horn, op cit. pp. 181-183.

It is definitely stated in the oath itself but understanding it is a different matter entirely. In the classical version, it is quite clear and it is hard to imagine that anybody of reasonable education can misunderstand that the way you treat your parents and siblings to your services would be to treat them with the best of your abilities and more importantly, for free. But it must be noted that it does not say that this also applies to your colleagues in the profession. However, ignoring the first modern version that removed any mention of this practice entirely, the second modern version can even be called vague. Unlike the classical version that explicitly says that their services will be for free, this time it only says just and generous which can be interpreted in various ways ranging from free to your guess as to the definition of just and generous which in any setting is as good as mine. Lastly, in the Declaration of Geneva, the difficulty in understanding is even worse. It only says that colleagues will be treated like siblings and nothing else; ultimately leaving the entire thing open to personal interpretation. I am astounded by the drastic changes of this part of the oath over the course of time. It should be noted that unlike the classical version of the Hippocratic Oath, the second modern version and the Declaration of Geneva both specifically refer to your colleagues in the medical practice. All the three versions that mention this custom can be misunderstood in one way or another, either you cannot tell who you are going to treat for free or you cannot tell whether your services should be for free or not. For a long time it has been merely a guideline, a sort of binding promise and all medical practitioners know it so when they seek the aid of one of their colleagues, they expect it to be followed. But now, in some countries where it is not required to follow this practice, medical practitioners do not do it. The reverse is true for countries that actually require it by law to be followed. For example, in the Philippine setting there is a rule in the Philippine Medical Associations Code of Ethics that requires medical practitioners to follow with regards to this practice: ARTICLE IV DUTIES OF PHYSICIANS TO THEIR COLLEAGUES AND TO THE PROFESSION

Section 1. A physician shall waive his professional fees to a colleague, his or her spouse, children and parents who are financially dependent on him.8 And this is the reason why medical practitioners follow this practice in our country. Here, it is a law. There is actually a rule regarding this practice in a higher level. In the International Code of Medical Ethics (ICME), it is stated that: DUTIES OF PHYSICIANS TO EACH OTHER A PHYSICIAN SHALL behave towards his colleagues as he would have them behave towards him. A PHYSICIAN SHALL NOT entice patients from his colleagues. A PHYSICIAN SHALL observe the principles of the "Declaration of Geneva" approved by the World Medical Association.9 But it is not clear whether they are required to follow this practice in the ICME and in the Declaration of Geneva. However in the Philippine setting, and I cannot stress this enough, the practice of giving free medical services to fellow medical practitioners is required for all medical practitioners in the country to follow. It is stated clearly in the PMA Code of Ethics Article 4 Section 1. In accordance to the article above, medical practitioners in the Philippines are to provide free medical services to their colleagues regardless of whether they are willing to do so or not. It does not matter whether the physicians want to provide their services and it also does not matter whether the physician can even afford to give free services, as long as the patient is a colleague, the service will be given for free. In our country, it is not just a custom, it is law and our medical practitioners are bound by it. However, although in some countries that do not require medical practitioners to follow this, some people still do. This custom applies of course not only to all physicians but to all people in medical practice. And not only limited to the individual practitioners themselves but also to their
8 9

Code of Ethics of the Philippine Medical Association. Article IV, Sec. 1. Horn, op cit. pp. 181-183.

immediate family. Many people are convinced that if your brother or sister or uncle is a doctor, you are also under immediate family. But that is not the case here, the law that medical practitioners follow does not mention you. What immediate family means is the medical practitioners spouse, children and parents who are dependent on him/her. And this is regardless of the number of children the individual has. So I think that if you have a sibling who is a doctor, it would be a very good idea to stay in good terms with them. The law allows medical practitioners to completely wave any and all fees for their services when the patient is a fellow medical practitioner or a member of the immediate family of a medical practitioner. Supposedly and ideally, this is supposed to extend to any and all kinds of medical treatments or services without exception. But that was before, back when physicians owned their own gadgets and tools and paid for their own supplies. But in todays world where most medical practitioners can be found working in public or private hospitals or clinics, this would only cover the fees that will be received by the physician or medical practitioner. The service itself is for free but the patient (who is also a medical practitioner) is still required to pay for whatever other fees might be included. It does not exempt them from all of the things included in the total bill. For instance, suppose a doctor (D1) needs to undergo a surgery. The surgeon (D2) will do it and will not receive any payment for the procedure but D1 will still have to pay the hospital for the room, the equipment, etc. In short, D2 doesnt get paid and D1 isnt exempted from paying the hospital. The medical practitioners only get a discount. I consider this to be very sad for the practitioners. Because doctors do not get paid as much as we think they do. We all know that surgeries are expensive and because of this, we think that the doctors earn a lot of money for each surgery they do. But this is not the case. The doctors/surgeons will only get a small portion of what we paid for which average at about 10% depending on the type of hospital because government hospitals pay less. So for instance D1 goes for a surgery and D2 has to follow the custom because they are in the Philippines. After the surgery D1 gets a Php 20,000.00 bill. D2 will only get about Php 1,500 to 2,500 of that and since D1 is a medical practitioner, D2 doesnt get anything but D1 will still have to pay the hospital the rest of the amount.

For the most part, especially in countries where this is law, it is followed. For example, in the Philippines, medical practitioners are required by law to give this free medical service to the immediate family members of another medical practitioner and they can be reported to higher authorities in the case that they do not. But according to the medical practitioners that I have talked to, this particular practice is followed only most of the time. They say most of the time because not all medical practitioners are willing to follow this rule especially in the private practices. Either they do not give free medical services altogether or they only give a certain discount for their colleagues. The reason, they say is because of the hard times and even with all their work, the income they generate is still not enough to support their families. This is even more for those who serve at public hospitals. And out of respect and because they also understand what their colleagues mean and feel, most medical practitioners do not report these cases to the proper authorities. They generally say that they are having a tough time with following this practice. For one thing, they do want other medical practitioners to follow this when they are the ones who will benefit from it. But in the instance where they will be the ones giving the free medical service, they themselves do not want to. As most of us would agree, these medical practitioners have to be compensated for their services. Benedict M. Ashley and Kevin D. ORourke present the argument in their book Ethics of Health Care. They say that it is more of a duty of the patient to pay for the physicians fees and it is the physicians right to be paid because of all the effort that they put into their work and the great responsibility that is accompanied by their profession.10 But they further say that, In health care the problem of mutual responsibility is crucial. If health care professionals do not care enough about each other and their common enterprise to accept the painful task of maintaining group standards in a fraternal and humane way, they cannot hope to personalize health care.11

10

Benedict M. Ashley and Kevin D. ORourke, Ethics and Health Care, (The Catholic Association of the United States, 1996), pp. 50-51. 11 Ibid. p. 54

If we follow this line of thought, then they should follow this custom because if their reason is simply because money is hard to earn, it gives all the more reason to help each other out. It isnt the case that they will give their services for free for everybody, only their colleagues and their immediate families will have that privilege and in turn their own family will also enjoy the same. So they should just follow the practice. And also, following it reduces the risk of being reported to be violating the PMA rule and being fined if they get reported. What Im saying is that the advantages of giving free services other medical practitioners and their immediate families are that they can expect to receive the same treatment for themselves and their families. The only downside is that you dont get the earnings that you would get if you made them pay. I think that it is more advantageous for a medical practitioner to give free medical services to their colleagues because in the long run, when they would need it, they could potentially save more money than what they would earn if they made everybody pay. Its a winning situation specially since they are not getting any younger and eventually t hey will need their colleagues services. This is originally supposed to be virtue based practice as with all the other principles mentioned in the Hippocratic Oath. But in todays world, I think that this would be utilitarian at best. I think so because this would be very advantageous to the medical practitioners that require the services of other medical practitioners. To put it into perspective, for instance suppose that there is a doctor (D1) and he needs a check-up from another doctor (D2) who specializes in another field of medical practice. In the effect of this practice, it would be very advantageous for D1 because D2 would do the check-up for free and likewise if D2 ever needs the professional help of D1, D1 would also do it for free. I dont think that this is Kantian at all because if there is a practice and more importantly, a law that dictates what action must be followed, then it is no longer a function of goodwill and cannot be Kantian. It might follow the universalizability of actions but you are usually not following it on your own accord. Instead, you follow it because it is required by law and because if you do not follow it, you might be reported to the higher authorities and duly punished. Despite my statement above that this is a utilitarian practice and not Kantian; I do not believe that this is a purely utility-based practice. It may be utilitarian for most cases but

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sometimes, in rare cases, a kind medical practitioner will do this regardless of whether there is a law or of whether he will be punished or not. He will just do it out of pure goodwill. To summarize, (1) the custom of medical practitioners providing free medical services for their colleagues really is something that is mentioned in the Hippocratic Oath and has for the most part remained there for a very long time and has survived many revisions. (2) It is definitely mentioned in the oath, but it is not literally said and can be understood somewhat differently. (3) It is not required and medical practitioners are not forced to follow this custom in some countries but in the case of the Philippines, it is required by the PMA (Philippine Medical Association). (4) It does not only apply for individuals but for that individuals immediate family as well. (5) Medical practitioners are the ones who decide whether they will follow this practice or not but because of the financial situation of the country, they are more inclined to not follow it. (6) Following this is deemed more advantageous than not following. (7) Lastly, it may be more utilitarian but it can be Kantian if we remove the law and if every medical practitioner will do it (albeit this is wishful thinking). I conclude that yes, doctors should still follow the custom of giving free medical services to their colleagues. And I also think that regardless of the PMA law, they should still follow it. Medical practitioners may not like it but I believe that it will benefit them in the future. On a side note, I may have also found out why in the past many parents wanted their children to become doctors. Free medical services when they get old are very tempting indeed. However, my conclusion is still subject to revisions because finding related works on this subject proved to be very difficult. There is a noticeable lack of focus on this type of relationship that a physician or any medical practitioner can encounter. Although almost all bioethics books tackle the issue of the patient-physician relationship, there is almost no mention of patientphysician relationships and the patient is also a physician.

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